Large Joints Feature

Recognize, Treat Meniscal Root Tears!

Elizabeth Hofheinz, M.P.H., M.Ed. • Fri, November 25th, 2016

A team of researchers from Baylor College of Medicine has just published a paper in RadioGraphics indicating the importance of recognizing and treating tears of the root of the meniscus. In their paper, they offer communication tools that can help radiologists and surgeons obtain clarity.

“Tears at the root of the lateral or medial meniscus can be a cause of knee pain, and while a root tear might be suspected during an exam, an MRI scan is the best diagnostic modality of picking up these injuries, ” said Theodore Shybut, M.D., assistant professor of orthopedic surgery at Baylor and a co-author of the paper, in the November 14, 2016 news release.

“The biomechanics research suggests that if you can repair the root and get it to heal, you may help postpone osteoarthritis of the knee on the medial side. On the lateral side, you are usually addressing instability, ” said Shybut. “Raising awareness of these injuries is important so radiologists and surgeons are looking for them, ” said Shybut.

Dr. Shybut told OTW, “Meniscal root tears are more common than many orthopedic surgeons and musculoskeletal radiologists realize. Medial tears are frequently seen in middle-aged people and can be degenerative. Lateral root tears are often seen in the setting of anterior cruciate ligament (ACL) injury. The biomechanical consequences of root tear are significant for knee instability and increased peak loading of articular cartilage in the involved knee compartment. Treatment of medial root tears with a degenerative component remains challenging.”

“Reviewing images from Dr. [Robert] LaPrade’s classification of meniscal root tears is always educational. Some of those tear patterns are uncommon but it is important to be aware of them—I recently repaired a type 3 root tear (bucket handle meniscal tear with root detachment) in the setting of revision ACL surgery.”

Other authors of the paper include Dr. Andrew R. Palisch, Dr. Ronald R. Winters, Dr. Marc H. Willis and Dr. Collin D. Bray, all with Baylor College of Medicine.

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Dr. Robert LaPrade Creates Video Series for Doctors, Patients

Elizabeth Hofheinz, M.P.H., M.Ed. • Fri, September 4th, 2015

Robert LaPrade, M.D., Ph.D., an orthopedic knee and sports medicine surgeon at The Steadman Clinic, has launched a new video series that is meant to educate non-orthopedic physicians, medical students and patients on reading an MRI of the knee. In this video series, “How to Read a MRI of the Knee, ” Dr. LaPrade reviews individual MRIs and identifies the various anatomic structures and visual indicators of common knee injuries.

As indicated in the news release, “Once the healthy anatomical structures are established Dr. LaPrade demonstrates how to read a MRI of the knee for ACL, PCL, MCL and PLC [anterior cruciate ligament, posterior cruciate ligament, medial cruciate ligament, and posterolateral corner] injuries, meniscal root tears, medial meniscus tears and osteochondritis dissecans lesions. In each case, he thoroughly examines all three MRI views to identify if there is bone bruising or an additional injury present.”

Dr. LaPrade told OTW, “I did this project because I believe it is essential that orthopaedic surgeons read their own MRI scans. We know the anatomy, have the benefit of a physical exam to match the anatomy and also need to confirm the findings ourselves.”

“It has been a bit frustrating to me that some of our incoming fellows will ask to look at the MRI report instead of actually viewing the MRI scans themselves. I can understand that sometimes some of them may not have exposure to some of the complex knee injuries that we see, but one should be able to interpret meniscal tears, meniscal root tears, ACL tears and other common pathology. By the end of their year here, I believe all of our fellows have excellent skill levels in reading most knee MRI scans. I found myself teaching the same points over and over again because I can only teach a limited number of sports fellows and Certified Athletic Trainer fellows each year.”

“I thus decided to create this education tool to benefit medical students, residents, fellows and other levels and types of physicians to help understand how to read a knee MRI scan. This may be especially helpful when one needs to interpret an MRI with a patient in the office and a radiology report may not be available for several days.

First Meniscus Replacements in Texas With NUsurface Implant

Elizabeth Hofheinz, M.P.H., M.Ed. • Mon, February 20th, 2017

Joseph Berman, M.D. of Arlington Orthopedic Associates, P.A. has performed the first meniscus replacement procedures in Texas using the NUsurface implant, made by Active Implants LLC.

According to the February 9, 2017 news release, “Arlington Orthopedic Associates and its affiliate Baylor Orthopedic and Spine Hospital is the only center in the state—and one of just 10 sites nationwide—enrolling patients with persistent knee pain caused by injured or deteriorating meniscus cartilage in the SUN trial, which is designed to assess the safety and effectiveness of the NUsurface Meniscus Implant (pronounced “new surface”) in restoring function similar to that of a natural, healthy meniscus.”

Dr. Berman told OTW, “My most exciting part of this project is to be on the cutting edge of changing the algorithm by which we will address meniscus injury in the future. The possibilities are amazing; revolutionary is the idea of quickly and easily replacing a meniscus with an inert implant that will reproduce the functions of spacing and shock absorption. The idea of being able to possibly prevent arthritis as an inevitable consequence of medial meniscus excision is unheard of. Medial meniscus surgery is one of the most common causes of subsequent unicondylar or total knee arthroplasty—albeit 10 – 20 years later. Yet, the cascade of injury starts after the index surgery. This implant gives the hope of preventing that cascade of events, decreasing the mid-life disabilities associated with medial compartment arthritis.”

Asked about the future of meniscus replacement in Texas, Dr. Berman told OTW, “I think the state of Texas, as well as around the USA, will see a change of how active individuals are treated when they tear a meniscus. Meniscus tears can be debilitating and can have implications far beyond the index surgery. In my opinion, I think the future of the NUsurface will be immediate implantation to those with significant meniscus tears; an exchange of the torn meniscus for the artificial one. This has not yet been done and our FDA study will not allow this, but I believe the future indications will become more liberal. What that means to a state such as Texas, where people are active athletically, will be to allow continued higher levels of function.

Study Begins on Meniscus Tears

Biloine W. Young • Mon, December 15th, 2014

The first patient has been enrolled in a study called STITCH to evaluate a suture-based meniscal repair for patients with horizontal meniscus tears. This is a common type of knee injury. The study is being conducted by Ceterix Orthopaedics, Inc. of Menlo Park, California.

Patients with horizontal cleavage tears often undergo the partial removal of the meniscus (meniscectomy) because doctors have believed that meniscus repair is not effective for this tear type.

“Since the early days of meniscal repair surgery, it has been often repeated, on the podium and in and publications, that horizontal cleavage tears cannot be repaired due to their degenerative nature, ” said orthopedic surgeon Peter Kurzweil, M.D., principal investigator of the STITCH study. “This study is designed to further investigate whether these types of tears can indeed heal, as the literature review suggests, when repaired with suture-based therapy.”

According to the company’s press release, a recently published systemic literature review shows that healing rates for horizontal cleavage tears are comparable to other meniscal tear types that are routinely repaired.

The release describes arthroscopic surgery as a minimally invasive surgical procedure performed by an orthopedic physician in which a damaged joint is treated, through small incisions with specialized tools, under the guidance of a tiny camera. Meniscus surgeries are the most common arthroscopic surgery in the United States, with roughly one million procedures performed annually.

Ceterix’s NovoStitch suture passer enables surgeons to place stitches arthroscopically in tight joint compartments and thereby address complex knee, hip and shoulder injuries that, the company maintains, have not been amenable to repair in the past.

New Study: RSA Improves Meniscal Transplant Matching

Tracey Romero • Thu, February 23rd, 2017

Researchers from Houston Methodist Orthopedics & Sports Medicine reported in the December issue of the Orthopaedic Journal of Sports Medicine that a new technique using Roentgen Stereophotogrammetric Analysis (RSA) allows for the explanting and re-implanting of native meniscus to improve matching for lateral meniscus transplantation.

“One of the problems in doing meniscal transplant kinematic research is that we cannot get a sufficient number of clinically acceptable host-donor size and side matches, Patrick C. McCulloch, M.D., John S. Dunn Chair of Orthopedic Surgery at Houston Methodist Hospital in Houston, Texas, told OTW. “I may have 10 cadaver knees, but the likelihood of finding appropriate size matches would require that dozens more knees be screened. That is why we developed this novel technique of explanting the native meniscus with a sliver of bone after testing, embedding it in plastic with [RSA] beads, and re-implanting it as a ‘best case scenario’ perfect match.”

In this study, McCulloch and colleagues used RSA to evaluate the meniscus of eight cadaver knees at 0°, 30°, 90°, and 115° of knee flexion. Measurements were taken for three states: the native lateral meniscus, an anatomic autograft transplant and a nonanatomic autograft transplant with an anteriorized posterior root position.

According to the results, the largest lateral translation in the native state was 2.38 ± 1.58 mm at the anterolateral region from 0° to 90°, which was increased to 3.28 ± 1.39 mm (p= .25) and 3.12 ± 1.18 mm (p = .30) in the anatomic and nonanatomic transplant states. The native meniscus distributed load over 223 mm2, while both the anatomic (160 mm2) and nonanatomic (102 mm2) states concentrated pressure anteriorly to the tibial plateau centroid.

“The study shows that the kinematics and contact pressures are partially restored to the native levels after transplantation and that subtle changes in root position result in measureable changes to each. Perhaps more importantly, I feel this study is a proof of concept that RSA can be used for meniscus research and that the development of this novel technique of allowing us to use the native meniscus as a transplant opens new avenues for meniscal research,” McCulloch said.

Stem Cell Injections Treating Sports-Related Pain

Biloine W. Young • Tue, February 27th, 2018

According to a Baylor College of Medicine expert those seeking relief from sports-related injuries due to conditions like osteoarthritis of the knee, partial rotator cuff tears, joint and tendon injuries, or tennis elbow may find it in a fat-derived stem cell injection.

“With this treatment, I can tackle a number of non-operative sports and musculoskeletal injuries,” said Prathap Jayaram, M.D., director of regenerative sports medicine and assistant professor of physical medicine and rehabilitation at Baylor.

“Some patients who may be candidates for a stem cell-derived injection are those with partial tears of a rotator cuff and knee osteoarthritis. There is an increasing body of evidence to support regenerative strategies that are beneficial for patients with joint and tendon injuries,” he said.

Jayaram, who trained at Stanford’s noted orthopedics department, offers an alternative—a non-operative procedure that can have patients in and out in one day. There are two types of stem cell-derived treatments available, he noted. In addition to the fat-derived stem cell therapy, a bone marrow stem cell therapy also is available.

“Unlike the bone marrow stem cell therapy, which has been available for some time, the fat-derived stem cell therapy can be gathered from an individual using minimally invasive techniques with minimal side effects. This treatment helps modulate the inflammatory profile in the joints and optimizes the patient’s own regenerative potential to help alleviate pain and improve function.” said Jayaram.

Often, patients will try repeated steroid injections which have limitations. Although steroids are great for acute pain, Jayaram said that over time, steroid injections can be more degenerative than regenerative at the tissue level and are not the best long-term option. “Certainly steroids still have a place, and I still inject steroids for acute pain where it’s indicated, but I don’t use it as a long-term strategy,” he said. This treatment has been FDA approved and is safe for patients, Jayaram said.